Can hormone therapy be used to treat endometriosis?

Hormone Therapy for Endometriosis

Hormone therapy is strongly recommended as the first-line treatment for endometriosis-associated pain, with progestin-only options showing superior efficacy and safety profile for most patients. 1

Treatment Algorithm for Endometriosis

First-Line Hormonal Options

• Combined Hormonal Contraceptives (CHCs)

  • Standard starting dose: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate
  • Preferably used in continuous regimen to suppress menstruation
  • Best for patients without contraindications to estrogen 1
  • Particularly effective for preventing endometrioma recurrence post-surgery 2

• Levonorgestrel-releasing IUD (LNG-IUD)

  • Highly effective for endometriosis-associated pain
  • Provides localized progestin effect with fewer systemic side effects
  • Excellent option for patients with contraindications to estrogen 1

Second-Line Hormonal Options

• Progestin-only pills (desogestrel, dienogest)

  • Dienogest has become one of the most widely used progestins for all endometriosis phenotypes 3
  • Effective for long-term management with reduced side effects 1

• Etonogestrel implant

  • Valid alternative for long-term treatment 3
  • Provides consistent hormonal suppression 1

• GnRH agonists with add-back therapy

  • Add-back therapy should include estrogens to prevent bone loss
  • Should be introduced before the third month of treatment
  • Not recommended solely to reduce endometrioma recurrence risk 2
  • Consider as last-line option due to side effect profile 4

Effectiveness and Mechanism of Action

Hormonal treatments work by:

1. Blocking menstruation through inhibition of hypothalamus-pituitary-ovary axis
2. Causing pseudodecidualization with consequent amenorrhea
3. Impairing progression of endometriotic implants 5

These mechanisms address the underlying hormonal imbalances in endometriosis:

• Estrogen dependency
• Progesterone resistance
• Increased inflammation and oxidative stress 5

Treatment Selection Based on Clinical Presentation

For Pain Management

• For dysmenorrhea: Continuous CHCs or progestins are most effective 1
• For deep dyspareunia: Both surgical and hormonal approaches can be effective; hormonal therapy provides gradual but progressive relief 1

For Post-Surgical Management

• After surgical treatment: Hormonal therapy is recommended to prevent pain recurrence and improve quality of life 2
• To prevent endometrioma recurrence: COCs are advised and should be maintained long-term if well tolerated 2
• For dysmenorrhea post-surgery: Use COCs in a continuous scheme 2

Monitoring and Follow-up

• Evaluate treatment response after 3-6 months
• Be aware that 25-44% of patients experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 1
• Monitor blood pressure at follow-up visits for CHC users
• Consider cardiovascular risk factors, as endometriosis is associated with increased risk of hypertension, elevated cholesterol, and inflammation 1

Important Caveats

• Hormonal treatment cannot be used in women actively trying to conceive 2
• Preoperative hormonal treatment is not supported for the sole purpose of reducing complications or facilitating surgical procedures 2
• GnRH analogs should be used with add-back therapy to prevent bone loss and improve quality of life 2
• For patients with specific stroke risk factors (age >35 years, tobacco use, hypertension, or migraine with aura), progestin-only options are preferable to estrogen-containing contraception 1

Hormone therapy represents a shift from the traditional primary surgical approach to endometriosis management, offering effective symptom control and potentially delaying disease progression when used appropriately 3.